IMAGE EVALUATION TEST TARGET (MT-3) / ^/ O 7, 1.0 I.I l:^ P2.8 |50 ^ M 22 1.8 1.25 1.4 1.6 «« 6" - ► V] <^ n / -%!,. W ^ "* ^ '/ M PhotDgraphic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 CIHM/ICMH Microfiche Series. CIHIVI/ICMH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques J. Technical and Bibliographic Notes/Notes techniquas at bibliographiquas The Institute has attempted to obtain the best original copy available for filming. 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Lorsque le document est trop grand pour Atre reproduit en un seul wllchA, il est filmA d partir da I'angle supArieur gauche, de gauche d droite, et de haut en bas, en prenant le nombre d'images nicessaire. Les diagrammer suivants illustrent la mAthode. 1 2 3 1 2 3 4 5 6 n^k The Methods Employed in Examin- ing the Eyes for the Detection of Hysteria rip«eiited to the Hectioii on NeuroloKy and Medical Jurisprndence, at tl»e Forty-nintli Annnal Meeting of the American Medical Associa- tion held at Denver, (.'olo.. June 7-10. 1898. BY CASEY A. WOOD, M.D. (■Ht(;AOO. REPRrNTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, NOVEMBER i.', 1S98. OHICAGO: American Medical Association Pkess. 1898. ■'•*'^,..^i^s?5!aiHaj»ffi«sse^^ THK METHODS EMPLOYED IN EXAMINING THE EYES FOR THE DETECTION OF HYSTERIA. '33 BV CASEV A. WOOD, M.D. Although much has been written regarding the vaUie of the ocular signs and symptoms of hysteria in the difignosis of that disease, I believe there is good reason for returning to several matters in this connec- tion that seem to me of vital importance, especially as I do not think sufficient stress is commonly laid upon the means by which one must arrive at diagnostic conclusions. My own belief, after a somewhat extended acquain- tance with this disease is, that, if one were to make a special study of that organ that m(-)8t uniformly exhib- its the evidence of hysteria, the eyv would afford the most informatitjn, even more emphatically than the skin or the mucous membranes. On the other hand, anomalies of the general sensibility are probably more easily detected by the average individual (who methodically searches for them) than are ocular defects. But as the scientific observer omits no ex- amination that will assist him in arriving at proper C(Miclusions in diagnosis, prognosis or therapy, I enter a plea for a mori! thorough and more general use of certain methods employed by the ophtTialmologist in detecting the presence of ocular hysteria as one man- ifest of the general neurosis. First of all, then, what are the commonest ocular manifestations of hysteria, what the most reliable means for their detection, and how may errors in examination be avoided? I need hardly say that Bonie acciuaintjince with the use of the ophth scope is of ^reat value in the dingnosisof ooulai teria, and in investigating the wubjoct one shou cartain that there are no alterations in the inter the eye to account for the visual disturbancet is not fitting that I should point out the val ophthalmos(^opic examinations to the trained m ogist: I do not very well see how he can disj with them. Should he be unable to examiu( background of the eye with the mirror he shou all events, seek a report upon the condition ol fundus at the hands of some oonfr6re expert in work. As is the case with other organs of the 1 there are absolutely no tissue alterations to be f in any part of the eye, due to the presence of hys A negative report upon the fundus conditio] therefore, a si'nr qua noii in examining a suspi hysterope. ANOMALIES OF ACX'OMMODATION. Taking one age with another, the commonest o sign of hysteria is a defect in the focusiiig pow the eye — anomalies of accommodation, ^r va reasons these conditions have been called A/y/; uisufficicncy of accommodation, ciliary parcs^ paralysis, painful accomimxhttion, nervous as opia, etc. The patient complains of the usual s; toms of asthenopia — pain in the eyes and fore when attemx^ting to read or do any other near \ blurring of print, photophobia, frequent winking These cases are rarely permanently relieved by gT or by an exclusive lo(^al treatment of the eye. I there is a defect in the range of accommodntion. so-called paresis of accommodation is nearly al in the form of a true hysteric contracture of the iary muscle- the motor power by which the e^ focused for various distances. The nearest poin which the eye can accommodate itself for the dis seeing of small objects varies with the age of the vidua!. As you are well aware, this point is < close to the eye in childhood, remote from it ii n^ *o of flu' ophtlialmo- ignosie of ocular hys- ubject one should be one in the interior of iial disturbances. It int out the value of 1) the trained neurol- ow he can dispense able to examine the mirror he should at he condition of the nfr^re expert in that • organs of the body, derations to l)e found presence of hysteria, undus condition is, imining a suspected «()I>ATI()N. he commonest ocular lie focusiiig power of >dation. For various been called hysteric , ciluiry paresis or on, nervous asthni- 8 of the usual symp- B eyes and forehead ny other near work, equent winking, etc. y relieved by glasses t of the eye. In all icommodntion. This ion is nearly always ntracture of the cil- y which the eye is he nearest point for tself for the distinct the age of the indi- this point is quite lote from it in old 3 nge. On the other hand, every eye has a certain range of accommodation ; that is, there is a certain space within which small objects ean be distinctly seen, and when the eye is normal, or when the refraction is ren- dered normal by distance glasses, this range is singu- larly and wonderfully constant in individuals of the same age, and I- believe that the neurologist who is on the lookout for devialions from the normal accommo- dations will obtain assistance in diagnosis by bearing this fact in mind For all practical purposes, how- ever, one may ignore the extent of this accommoda- tive range and confine one's attention to the nearest point of distinct vision, that is almost always affected in hysteria, that is to say, is usually too near or too far away from the eye of the hysterope. The follow- ing table indicates the proper distance, and it is a very easy thing to determine any deviation: Nearest point of Akb. difltinct vision. 10 7 cm. 15 8 20 10 25 11.7 " 30 14 um. 35 18 40 22 45 28.0 " 50 40.5 " An eye that is under the influence of hysteria acts either as if it were under the influence of pilocarpin or atropin; the patient is able to read fine print either abnormally near or sees small objects most distinctly farther away than he should. In practice, all that it is necessary to do is to have tlie distant vision, if abnormal, corrected by glasses and then ask the suspected individual to read the finest diamond print, held as near to the eye as possi- ble. The patient, with his back to a good light, is asked to read a portion of a page of this print, at the normal distance from the eye, as shown by the table. If he continues to read it when brought a couple of centimeters or more nearer, or if he cannot read un- loBH it is vem*»ved fftrther away than the n<>rrnal tance, a defect of accommodation is certainly pren I recommend this as one of the most satisfactory most easily applied of all the tests. As in other fo of spasm or paralysis of accommodation, the co tion may often he relieved by glasses. It often 1 pens that a youn^' subject must be treated as it were sixty years of a^e, requiring a strong cor glass for reading' at the normal distance or a cone glass for street wear. In both instances a few di of a 1 per cent, solution of atropia will disclose true refraction, often unmasking the hysteric chara of the defect. DEKKCTS IN THK FIELD OF VISION. As every neurologist knows, defects in the fiel< vision constitute some of the commonest signi disease of the ocular apparatus, and that they ai paramount importance, while a knowledge of t peculiarities is of great value in determining presence of hysteria. For purposes of comparisc show two perimeter charts: one of the normal and the other furnished by a hysteropo under my ( The predominant peculiarity of an hysteric anor of the visual field is, that while in every other dis (except hysteria) where peripheral limitations oc the color field is atfected pari fHtssn, or in n gn proportion than the field for white. In non-hysl diseases perception of color is often entirely lost, yet fairly large areas susceptible to visual sensa from a white disc remain. In hysteric amblyopin field for colors is of greater extent or is less afle proportionately than the field for white objects, fhc rererse of tliaf irliirh (ihtains in other tier (iJJ'cctiotts. Kven where the field for white is still largest it can usually be shown (when there is perimetric defect) that the visual field for red is la than that for blue, and measurements for these c( should always be made in doubtful cases. On the best examples of this reversal of the color /37 lan the norninl die- ie certainly preHeiit. oat satisfactory and V As in other forms lodalion, the condi- B8VB. It often liap. bo freated as if he IK a strong convex intance or a concave stances a few drops >ia will disclose the le hysteric character OF VISION. fects in the field of ioniinonest signs of md tliat they are of knowledge of tlieir in determining the ses of comparison, I of the normal field )ropo undei- my care, m hysteric anomaly 1 eveiy other disease il limitations occnr, ssn. or in a greater e. In non-hysteric [•n entirely lost, and to visual sensation iteric amblyopia the t or is less affected white o])jects, ///8/ IS in other ncrrous For white is still the when there is (niij field for red is larger )nts for these colors tful cases. One of I of the color field occurred in the case of a young lady, aged 17, in deli- cate health, who began to complain of her eyes. She then noticed that she could not see well in the distance or read ordinary print with the right eye. There were no fundus changes; patient was distinctly hysteric; had attacks of weeping-without apparent cause, phar- yngeal" anesthesia, lump in her throat, etc. She had spasm of accommodation, was able to read only (!oarse print and that at from <) to 10 cm. in front of tlie ey«'. She could not read line print at any distance. I wish you would especially notice that her field for red is larger than that for white. It must be remembered, that even where the patient does not complain of visual disturbances (juite marked defects of indirect vision may be present. If these do not proclaim themselves at once they may be devel- oped by fatigue of the retina The patient is asked to look steadily for a couple of minutt^s at a near object and then the field for red and green should be mapped out, followed by that for white, and vice versa. The amblyopia may be so marked that the field for white and colors is reduced to the vanishing point, a condi- tion of affairs which it is not improper to regard as an anesthesia of the perceptive elements of the retina and in correspondence with the loss or perversion of sensation exhibited by the skin and mucous membranes in other pliases of the disease. In such instances it rarely happens, even where the central vision is reduced to 1/10 or 1/20 of the normal, tha prevents the patient from walking about as if he i, .d good vision. I have now under my care a child who can not read the coarsest print at any distance, whose distant vision is reduced to finger counting at four feet and whose color- field and the area for white measure about 5 de- grees, and yet to all outward appearances she has good eyesight, that is, she does not stumble over small arti- cles of furniture placed in her path and her parents have difficulty in believing that her vision is defective. My principal reason for referring to these defec^ts in the visual field, so well known to all of you, is to 6 iiiBint upon a cortain form of examination. Hyflte is esHentially a fatigue neuroBiB and in the use o subjective test like the jierim^ter one may raBily obt evidence that is ([uitr mialeadinjr. In other woi mapping out the limits of the tield of vision in a h tiTope requires morr time and patience than is gen ally given to it. In my opinion, all uncomplioa caseH t)f hysteric defe<'t show a concentric contract * and n fairly uniform boundary of the visual tield. the case wiios*' tield I show you there were, when was first measured, several apparently reentrant ang but these disappeared when the patient was allov to close h« r eyes and rest for an instant every thi seconds during the examination. I do not think t hand perimeters, or objects simply held in front of face, should be used in examining hysteric patiei A stationary [)erimeter, accurately adjusted sho always be employed and the suspected hystep should remove th«' chin from the rest and close eyes fre(iuently during the examination. Moreo^ only one eye should be examined at a sitting and c trol tests must be repeatedly made. I have often 1 an opi>ortunity to observe the necessity for tak these precautions, and am convinced that impro conclusions may readily be drawn from the uf method of examination. MoNodLAR DIPLn.'I.A (»R l*«»I.V(>PIA is a curious hysteric phenom^n»>n, probably the rei of ciliary spasm. When care is takei not to sug^ it to the patient, it may l)e developed in many hys opes. I say developed, because, like defects in Held of vision, the patient is usually unconscioue the double vision, as such. It commonly pres( itself to him or her as part of the visual defect i the manner in which the examination is carried on of ^reat importance. A test should be made in b a lighted and darkened room. In the former, one being covered, a white match is held vertically tl or four inches in front of the uncovered eye. As i / 5c, I illation. Hysteria IK I in tlio use of a 10 may easily obtain In otlier words, of viHioii in a liyH- ■nct' than is gener- all uncomplicatt'd centric contraction hv visual Hc'hl, In lit're were, when it ly reentrant angles, aticnt waH allowt'd instant every thirty I do not think that held in front of the : hysteric patients. ly adjusted should ispt'cted hysterope rest and close the nation. Moreover. it a sitting and coii- . I have often had Bcessity for taking iced that improper vn from the usual I'OI.YOIM.V probably the result nkei not to suggest )ed in many hyster- like defects in the illy unconscious of commonly presents 3 visual defect and ion is carried out is Id be made in both the former, one eye eld vertically three rered eye. As it is slowly moved from its Hrst position to a point three or four feet away, the patient is asked how many matches he sees. In most cases the mat(^h will pre- sent a double image when held quite near the face; the images approach each other and become confused as they are removed, to again separate more and more until the meter distance is reached. The match is again, from this point, gradually brought close to the eye. when the same phenomena, but in reverse order, will be manifest. The second eye is similarly exam-« inod and, tinally, the room is (hirkened and a further ipsi((. Tsually ange symptom, prob- of the ciliary mus(rle, test for it. A long, h eye of the patient feet, and he in asked dT in size. Notes are ^riment repeated in a pinion, characteristic f the orbicularis, the this is unilateral and : spasm of accommo- ysteric, and I believe of the orbicularis are B form of blinking or r where the spasm is 8 the facial muscle. ffl